Free Authorization Form (PLRA) - District Court of Delaware - Delaware


File Size: 95.8 kB
Pages: 2
Date: May 17, 2005
File Format: PDF
State: Delaware
Category: District Court of Delaware
Author: unknown
Word Count: 290 Words, 1,929 Characters
Page Size: Letter (8 1/2" x 11")
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Case1:05-cv—00037—SLR D0cument14 Filed 05/16/2005 Page10f2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
HARRY SAMUEL, }
Plaintiff, g
v. g Civ. No. 05-037-SLR
THOMAS CARROLL, LT. PORTER, g ;·§; k;_ _,2
COUNSELOR KRAMER, I.B.C.C. ) _mq§ 3§E§§§,. q
(THE CLASSIFICATION ) , I· ······· ··‘0“t·M ‘·‘· L ,
COMMITTEE), and DENTAL ) g `, _:_ _ j j
SERVICE, g l i L i
Defendants. =-Hw~sD0eawAWe»~° ¥
1 ‘ .
AMENDED AUTHORIZATION
I, Harry Samuel, request and authorize the agency holding me
in custody to disburse to the Clerk of the Court the initial
partial filing fee of $11.85 and the subsequent payments pursuant
to 28 U.S.C. § l915(b) and required by the Court’s order dated
Ll /3 . 2005.
This authorization is furnished in connection with the
filing of a civil action, and I understand that the filing fee
for the complaint is $150.00. I also understand that the entire
filing fee may be deducted from my trust account regardless of
the outcome of my civil action. This authorization shall apply
to any other agency into whose custody I may be transferred.
Date: 5» I3 , 2005.

Case1:05-cv—00037—SLR D0cument14 Filed 05/16/2005 Page20f2
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